Formulary Operations Pharmacist – Medicare

Formulary Operations Pharmacist – Medicare

Requirements

• Doctor of Pharmacy (PharmD) Degree from an accredited institution, with record of strong academic performance
• Current, unrestricted registered pharmacist license(s)
• Residency/fellowship preferred
• 2-3 years of formulary experience working for a health plan or PBM preferred
• 2-3 years of Medicare experience preferred
• Knowledge of formulary development and maintenance processes
• Knowledge of highly managed specialty medications/strategy
• Knowledge of rebate and financial implications of formulary strategies
• Experience working with large datasets preferred
• Ability to independently identify, research, and resolve issues
• Ability to balance multiple complex projects simultaneously
• Ability to work extended hours, weekends, and holidays consistent with industry demands
• Exceptional written and verbal communication skills
• Extremely flexible, highly organized, and able to shift priorities easily
• Attention to detail & commitment to delivering high quality work product
• Microsoft office suite with emphasis on Microsoft excel proficiency required

Responsibilities

• Maintain standard and custom formularies for the Medicare line of business in accordance with CMS Medicare guidelines
• Support development, implementation, maintenance, and quality control of Medicare Part D formularies, utilization management, and clinical adjudication drug lists
• Lead and support preparation of monthly and annual files for CMS formulary submissions, member formulary drug lists and look up tools, and utilization management criteria
• Evaluate drugs/drug classes, make formulary positioning and utilization management recommendations, and update formulary management strategies and associated adjudication requirements to operationalize
• Evaluate appropriateness of and operationalize custom client formulary and benefit change requests within the formulary and adjudication platform
• Support comprehensive testing of client formulary and benefit elections
• Provide cross functional support for claim troubleshooting within the adjudication platform
• Monitor and analyze regulatory and legislative requirements for Medicare
• Support development of project plans to meet new CMS requirements, and support cross functional teams with implementation of programs to meet requirements
• Lead formulary change processes within URAC/NCQA/CMS guidelines
• Pharmacy and Therapeutics (P&T) Committee participation as an ad hoc member
• Conduct formulary reviews and develop drug monographs based on a rotation of clinical pharmacists
• Maintain and update the Capital Rx pharmaceutical pipeline, as needed
• Develop clinical criteria for review as needed
• Support CMS formulary administration audits
• Support quality improvement projects as needed
• Support Request for Information (RFI) and Request for Proposal (RFP) submissions, as needed
• Support general business needs and operations, as needed
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Preferred Qualifications

• Residency/fellowship preferred
• 2-3 years of formulary experience working for a health plan or PBM preferred
• 2-3 years of Medicare experience preferred
• Experience working with large datasets preferred